The home health care nurse is visiting a child with renal failure undergoing continuous ambulatory peritoneal dialysis (CAPD). Which of the following would lead the nurse to identify a nursing diagnosis of fluid overload related to CAPD?

poor skin turgor

shortness of breath

Redness at the tube insertion site

Fever

Answer and Explanation

The Correct Answer is B

A. Poor skin turgor typically indicates dehydration, not fluid overload.

B. Shortness of breath can be a sign of fluid overload, particularly in children with renal failure, as excess fluid can accumulate and lead to pulmonary edema.

C. Redness at the tube insertion site may indicate infection but does not specifically relate to fluid overload.

D. Fever is a sign of infection or inflammation and does not directly indicate fluid overload.

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Free Nursing Study Resources

Correct Answer is ["8"]

Explanation

To calculate the dosage of diphenhydramine (Benadryl) for the child, we first determine the total milligrams needed per dose by multiplying the child's weight in kilograms by the prescribed milligrams per kilogram. The child weighs 20 kg, so the calculation is 20 kg * 5 mg/kg, which equals 100 mg per dose. The medication is supplied at a concentration of 12.5 mg per 5 ml. To find out how many milliliters are needed to provide 100 mg, we set up a proportion: 12.5 mg/5 ml = 100 mg/x ml. Solving for x gives us x = (100 mg * 5 ml) / 12.5 mg, which equals 40 ml. Therefore, the nurse will administer 40 milliliters of the medication for one dose.

A. Administer benadryl. B. Apply ice to the site. C. Give epinephrine. D. Determine if the sting is in situ

Correct Answer is C

Explanation

A. Administering Benadryl may help with allergic reactions but is not the immediate priority when the patient is showing signs of severe hypotension and respiratory distress.

B. Applying ice to the site may help with local swelling but does not address the systemic reaction the child is experiencing.

C. Giving epinephrine is the priority action as it counteracts the anaphylactic reaction, improves blood pressure, and alleviates respiratory distress.

D. Determining if the sting is in situ is less critical than addressing the child's life-threatening symptoms.

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The home health care nurse is visiting a child with renal failure undergoing continuous ambulatory peritoneal dialysis (CAPD). Which of the following would lead the nurse to identify a nursing diagnosis of fluid overload related to CAPD?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["8"]

Explanation

A 9-year-old client presents to the emergency department after a bee sting and experiencing bouts of nausea and vomiting. The nurse notes the client's blood pressure is 68/40 mm Hg, pulse is 148 beats/minute. 02 saturation is 86%, and the child is dyspneic. Which action is the nurse's priority?

Correct Answer is C

Explanation

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